A Place to Call Home

Where you will always have Family

Volunteer Application

Name: Date:

Address:

Number and Street Apt# City Zip

Telephone: (W) (H) e-mail:

Daytime Phone: Nighttime Phone:

Email Address: Cell Phone:

Would you like to be on My Friend’s Place mailing list?  Yes No

What is the best way to reach you?

Date of Birth: Are you an MFP client or alumni?  Yes  No

If yes, when was the last date that you accessed services?

How did you hear about A Place to Call Home?

What do you hope to gain from your experience at A Place to Call Home?

Volunteer Commitment

How long are you planning on volunteering at A Place to Call Home?

Long TermShort TermSeasonalWhen available

Please indicate the best day and time for you to volunteer:

Monday / Tuesday / Wednesday / Thursday / Friday
Availability / AM/PM / AM/PM / AM/PM / AM/PM / AM/PM

Occupational Background

From: To:

From: To:

Please tell us about any interests, special skills, talents or passions that you would like to be able to share with A Place to Call Home

Interest

Direct Services

 Food Service

 Board and card games

Building client rapport

Stocking supplies/

Maintenance

Groups

 Music

Art

Employment/

Education

 Writing

 Computers

Health and Wellbeing

Behind the scenes

 Administration

 Special events

 Fundraising

Agency beautification

 Organizing donations

Emergency Information

Emergency Contact

NameRelationshipPhone#

Do you have any physical or mental well-being considerations that we should be aware of in order to support your success at A Place to Call Home?  Yes  No

If Yes, please explain:

References

Please list three references. Include two professional and one personal reference.

1. Phone:

2. Phone:

3. Phone:

Have you ever been convicted of a felony*?  Yes  No

If Yes, please explain:

The facts set forth above in my application are true and complete to the best of my knowledge. I hereby authorize you to make an investigation necessary to verify the information provided, and I consent to release this information to A Place to Call Home. I understand that as a volunteer I am required to abide by all the rules and regulations of A Place to Call Home

Signature

______Date:

Volunteers are considered for placement without regard to sex, race, creed, religion, color, national origin, age disability, marital status, pregnancy, veteran status, sexual orientation, gender identity or citizenship status. A Place to Call Home is an equal opportunity agency. *Applicants who indicate a felony conviction will not be summarily rejected. Please mail applications to 1234 Safe Place StreetHome, Portland, OR 12345If you would like to fax or email your application, please call 100 -555-5588